Recent research has shown that mortality rates increase during economic expansions and decrease during recessions. This counterintuitive finding has been replicated in several industrialized countries, but important questions remain regarding the relative contribution of different causes of death to this pattern and the specific pathways connecting macroeconomic fluctuations with mortality. It is also unclear what demographic groups are more affected. A better understanding of the relative contributions of different causes of death ant the vulnerability of different demographic groups will shed light on the causes of these fluctuations, and will help identify strategies to buffer the adverse health effects of economic expansions. Levels of atmospheric pollution, consumption of harmful substances and food, and conditions of work are affected by fluctuations of the economic activity, and could mediate the relation between economic fluctuations and mortality. However, empirical evidence regarding the relative importance of these pathways is scarce. Identifying such pathways is important not only to strengthen inferences regarding causal effects of economic fluctuations on mortality, but also to design preventive interventions. The overall goal of the project is to increase our understanding of the pathways linking fluctuations in the economy to fluctuations of mortality. In aims 1 to 3, this goal will be accomplished through panel analyses of annual/quarterly/monthly mortality data for states and Metropolitan Statistical Areas (MSAs) over the past 20-30 years, linked to economic data and data on potential mediators of the economic effects. In aim 4 we will ascertain the impact of economic fluctuations on survival using individual-level data from two nationally representative longitudinal studies of mortality-the National Health Interview Survey linked to subsequent mortality, and the NHANES I Epidemiologic follow-up Study (NHEFS). Aim 1 will examine differences in the effects of economic conditions for different causes of death. Aim 2 will examine whether effects are similar by age, sex, and race/ethnicity. Aim 3 will examine to what extent changes in selected variables including atmospheric pollution, traffic volume, consumption of harmful substances (alcohol, tobacco, and saturated fats), and changes in the work environment (weekly hours, overtime) explain the impact of macroeconomic conditions on mortality rates. Panel models will allow tight control for geographic and time-related confounders as well as sensitivity analyses by comparing estimates using different specifications. Aim 4 will use Cox models to examine the impact of economic conditions on individual-level survival after controlling for individual-level confounders. Mediators measured at the individual-level will also be examined. Understanding the pathways leading to increasing fatalities during economic expansions has major implications, not only for understanding the determinants of mortality trends generally, but also for the design of policies and interventions to reduce the harmful health effects of economic expansions. This R21 grant uses complementary analyses of population-level and individual-level data to achieve this goal. PUBLIC HEALTH RELEVANCE: Recent research has shown that total mortality increases during periods of economic expansion but the reasons for this increase remain poorly understood. Understanding differential vulnerability by sociodemographic groups as well as the major causes of death and the specific mediating mechanisms involved is fundamental to designing public health strategies to prevent and buffer the potentially harmful health effects of economic expansions.